Selective Serotonin Reuptake Inhibitors and Fertility: Considerations for Couples Trying to Conceive

The association between gestational selective serotonin reuptake inhibitor (SSRI) treatment and newborn thyroid screen: a large-scale cohort study

BACKGROUND

The diagnosis of depression or anxiety treated by SSRIs has become relatively common in women of childbearing age. However, the impact of gestational SSRI treatment on newborn thyroid function is lacking. We explored the impact of gestational SSRI treatment on newborn thyroid function as measured by the National Newborn Screening (NBS) Program and identified contributory factors.

METHODS

An observational large-scale study of mother-infant dyads of liveborn infants delivered between 2011 and 2022. The Israeli NBS Program thyroid dataset [total thyroxine (TT4) obtained between 36-72 h after delivery] was linked with the electronic medical records of mothers and their infants born at Lis Maternity and Women's Hospital, to generate a unified database. The MDClone big data platform was utilized to extract maternal, perinatal, and neonatal characteristics from the medical records of mother-infant dyads. Only term liveborn infants born to mothers without documented thyroid disease and/or chronic medication administration, except for SSRIs, were included in order to minimize potential confounding effects on the infant's thyroid function. Group stratification relied on the documentation of gestational SSRIs treatment. The variables of interest were maternal, pregnancy, delivery, and perinatal characteristics of the mother-infant dyads. Multivariable forward linear regression model was applied to evaluate explanatory variables for newborn total thyroxine (TT4) levels.

RESULTS

Out of 105,928 infant-mother dyads, 2321(2.2%) mothers had been treated with SSRIs during pregnancy. The SSRI-treated mothers were older (34.8 ± 4.7 vs 32.6 ± 4.8 years, p < 0.001) and had a higher pre-pregnancy body mass index (23.4 ± 4.5 vs 22.7 ± 4.1, p < 0.001), but similar mean weight gain (13 kg) during pregnancy. Cesarean delivery was more common among SSRI-treated mothers than in the general population (p < 0.001). Infants of SSRI-treated mothers had lower WHO-classified birthweight z-scores (-0.25 ± 0.93 vs -0.04 ± 0.92, p < 0.001) and a higher rate of small-for-gestational-age infants (13.4% vs 8.2%, p < 0.001). A multivariable forward linear regression model revealed that SSRI treatment during pregnancy was not a significant contributor to TT4 levels (p = 0.497).

CONCLUSIONS

SSRI treatment during pregnancy had no direct effect upon the newborn's adaptation of the hypothalamic-pituitary-thyroidal axis, but several other maternal and delivery characteristics were revealed to possibly impact newborn thyroid function.

Evaluating the Use of Selective Serotonin Reuptake Inhibitors (SSRIs) and Male Infertility: A Critical Retrospective Study

Background: The use of selective serotonin reuptake inhibitors (SSRIs) has been associated with potential effects on male fertility, although the exact mechanisms are not fully understood. The aim of this study was to understand the relationship between SSRIs and male infertility; Methods: A retrospective chart review of Saudi males who were treated with SSRIs and attended an infertility clinic in KSMC was undertaken. The medical records of men from an infertility clinic were reviewed to screen the quality of the sperm parameters in patients taking SSRIs; Results: In total, 299 men were identified, of whom 29 (9.6%) were exposed to SSRIs, while 270 (90.4%) did not receive SSRIs, defined as the control infertile group. When comparing the mean ages, a notable disparity was observed between the control group of infertile men (34.2 ± 6.9 years) and the infertile group using SSRIs (41.5 ± 3.2 years) (p < 0.001). Regarding the sperm analysis and the use of SSRIs, the impact of SSRIs use showed no significant differences in sperm liquefaction (p = 0.1), motility (p = 0.17), viscosity (p = 0.16), or count (p = 0.069) with escitalopram, fluoxetine, or paroxetine use; Conclusions: Our study showed no significant difference in the sperm analysis between the SSRI and non-SSRI cohorts. However, the relationship between SSRI use and sperm count warrants further investigation and consideration in clinical practice.

Paroxetine treatment in an animal model of depression improves sperm quality

Depression in mammals is known to be associated with poor reproductive capacity. In males, it has been associated with decreased efficiency of spermatogenesis as well as the production of spermatozoa of reduced structural and functional integrity. Although antidepressants are effective in correcting depressive states, there is controversy regarding their effectiveness in restoring male reproductive function. Here, using an animal model of depression induced by a forced swim test, we confirmed that depression is accompanied by impaired male reproductive function. We further show that administration of a conventional antidepressant of the serotonin reuptake inhibitor class (paroxetine) impairs male reproductive performance in terms of sperm production and quality when administered to healthy animals. Intriguingly, when paroxetine is administered to "depressed" animals, it resulted in a complete restoration of the animal's ability to produce sperm that appears to be as capable of meeting the parameters evaluated here as those of control animals. The one-carbon cycle (1CC) is one of the most important metabolic cycles that include the methionine and folate cycles and plays a major role in DNA synthesis, amino acids, and also the production of antioxidants. Our results show that depression affects the main components of this cycle and paroxetine on healthy mice increases homocysteine levels, decreases glycine and vitamin B12, while in depressed mice, it increases folate levels and decreases vitamin B12. Thus, paroxetine exerts negative impacts on male reproductive function when administered to healthy animals and it well correlate with the altered sperm parameters and functions of depressed animals, and its mechanism remains to be explored.

Alpha-lipoic acid-role in improving both reserpine toxicity and paroxetine treatment in the cerebral cortex of albino rats; histological, ultrastructural, immunohistohemical and biochemical studies

Background

Reserpine is a monoamine depletory drug cause oxidative damage and used to induce depression-like features in rodent model. Paroxetine is an antidepressant drug that exerts its effects by inhibiting dopaminergic neurons although it may exert much pathological damage. Alpha-lipoic acid (ALA) is an endogenous antioxidant co-factor of important enzymatic complexes. The present study was aimed to elucidate the possible protective effect of ALA in the improvement of the deleterious cerebral cortex injury after reserpine and paroxetine treatment. Forty adult male albino rats were equally divided into 5 groups. Group I served as control group orally treated with saline solution all the experiment period. Group II animals orally treated with ALA (200 mg/kg/day) for six weeks. The induction of depression-like features occurred when the rest of animals were intraperitoneally treated with 25 mg/kg of reserpine once daily for consecutive 14 day. Then these animals were divided into; Group III (reserpine group) animals in this group were sacrificed on 15th day. Group IV; reserpine-treated animals were treated with paroxetine (20 mg/kg) daily for 6 weeks. Group V, animals in this group were received paroxetine and ALA daily for 6 weeks.

Results

Reserpine-treated rats showed disorganized layers of cerebral cortex with degenerative, apoptotic and necrotic changes. Ultrastructure changes include both pyramidal and granule cells with severe degenerative, necrotic and apoptotic features. The nuclei appeared pyknotic; irregular with chromatin condensation as well as the cytoplasm of these cells contained many degenerated organelles. In addition, a significant increase in total oxidative stress and decrease in total antioxidant capacity, norepinephrine, dopamine and serotonin levels were recorded. The same treatment showed significant decrease in proliferating cell nuclear antigen (PCNA) expression and significant increase in caspase-3 expression in the granule and pyramidal cells. After paroxetine-treatment these parameters were more or less similar to those observed in reserpine-treated ones. While an obvious improvement was appeared when animal treated with both paroxetine and ALA and; all parameters restored its normal features.

Conclusions

This study concluded that; ALA treatment attenuated the cerebral injury induced by reserpine and improved the effects of paroxetine in rats due to its anti-inflammatory, anti-apoptotic and antioxidant activities.

The effects of selective serotonin reuptake inhibitors on male and female fertility: a brief literature review

Objective: The aim of this review was to determine whether selective serotonin reuptake inhibitors (SSRIs) affect the ability to conceive in men and women of reproductive age, as well as to find out whether there are certain differencies between them in terms of effects on fertility. Methods: Our review was based on systematic search of literature in four online databases: Medline (PubMed), Scopus, Web of Science and SCIndex (Serbian Citation Index). Results: Several clinical studies reported that SSRIs can decrease the number and viability of sperm, and cause a disruption of their morphological structure. Regarding the effect of these antidepressants on female fertility, some experimental findings suggest that paroxetine and escitalopram may have a negative effect on the ability to conceive due to their stimulatory effect on fallopian tube motility. However, several observational studies favor the use of SSRIs in women with depression/anxiety undergoing in vitro fertilization (IVF) given their efficiency in suppressing these unpleasant symptoms without a relevant negative impact on IVF outcomes. Conclusions: SSRIs should be avoided male patients of reproductive age who wish to conceive, while the use of these antidepressants seems to be justified in women with depression or anxiety who have undergone IVF.Key pointsSSRIs could cause dose and duration-dependent reversible adverse effects on male fertility parameters.In depressed or anxious male patients of reproductive age who wish to conceive mirtazapine or bupropion should be used because of their lower potential to cause sexual side effects.The results of certain experimental studies indicate that paroxetine and escitalopram may have a negative effect on the fertility of female patients.The use of SSRIs in women with depression or anxiety who have undergone IVF seems to be justified, because these psychiatric disorders reduce the likelihood of becoming pregnant.

The antidepressant Sertraline inhibits CatSper Ca2+ channels in human sperm

STUDY QUESTION

Do selective serotonin reuptake inhibitor (SSRI) antidepressants affect the function of human sperm?

SUMMARY ANSWER

The SSRI antidepressant Sertraline (e.g. Zoloft) inhibits the sperm-specific Ca²⁺ channel CatSper and affects human sperm function in vitro.

WHAT IS KNOWN ALREADY

In human sperm, CatSper translates changes of the chemical microenvironment into changes of the intracellular Ca²⁺ concentration ([Ca²⁺]_i) and swimming behavior. CatSper is promiscuously activated by oviductal ligands, but also by synthetic chemicals that might disturb the fertilization process. It is well known that SSRIs have off-target actions on Ca²⁺, Na⁺ and K⁺ channels in somatic cells. Whether SSRIs affect the activity of CatSper is, however, unknown.

STUDY DESIGN, SIZE, DURATION

We studied the action of the seven drugs belonging to the most commonly prescribed class of antidepressants, SSRIs, on resting [Ca²⁺]_i and Ca²⁺ influx via CatSper in human sperm. The SSRI Sertraline was selected for in-depth analysis of its action on steroid-, prostaglandin-, pH- and voltage-activation of human CatSper. Moreover, the action of Sertraline on sperm acrosomal exocytosis and penetration into viscous media was evaluated.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The activity of CatSper was investigated in sperm of healthy volunteers, using kinetic Ca²⁺ fluorimetry and patch-clamp recordings. Acrosomal exocytosis was investigated using Pisum sativum agglutinin and image cytometry. Sperm penetration in viscous media was evaluated using the Kremer test.

MAIN RESULTS AND THE ROLE OF CHANCE

Several SSRIs affected [Ca²⁺]_i and attenuated ligand-induced Ca²⁺ influx via CatSper. In particular, the SSRI Sertraline almost completely suppressed Ca²⁺ influx via CatSper. Remarkably, the drug was about four-fold more potent to suppress prostaglandin- versus steroid-induced Ca²⁺ influx. Sertraline also suppressed alkaline- and voltage-activation of CatSper, indicating that the drug directly inhibits the channel. Finally, Sertraline impaired ligand-induced acrosome reaction and sperm penetration into viscous media.

LIMITATIONS, REASONS FOR CAUTION

This is an in vitro study. Future studies have to assess the physiological relevance in vivo.

WIDER IMPLICATIONS OF THE FINDINGS

The off-target action of Sertraline on CatSper in human sperm might impair the fertilization process. In a research setting, Sertraline may be used to selectively inhibit prostaglandin-induced Ca²⁺ influx.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Swiss Centre for Applied Human Toxicology (SCAHT), the Département de l’Instruction Publique of the State of Geneva, the German Research Foundation (CRU326), the Interdisciplinary Center for Clinical Research, Münster (IZKF; Str/014/21), the Innovation Fund Denmark (grant numbers 14-2013-4) and the EDMaRC research grant from the Kirsten and Freddy Johansen’s Foundation. The authors declare that no conflict of interest could be perceived as prejudicing the impartiality of the research reported.

TRIAL REGISTRATION NUMBER

NA.

Neuro-pharmacological reinstatement of ovulation and associated neurobiology in a macaque model of functional hypothalamic amenorrhoea

STUDY QUESTION

What is the underlying neuropathology in a cynomolgus macaque model of functional hypothalamic amenorrhoea (FHA) and can it be normalized to restore ovulation?

SUMMARY ANSWER

Anovulatory monkeys exhibited increased hypothalamic norepinephrine (NE), kisspeptin and gonadotropin-releasing hormone (GnRH) in the early follicular phase, but administration of the NE reuptake inhibitor (NRI), reboxetine (REB), restored ovulation during stress and normalized NE, kisspeptin and GnRH.

WHAT IS KNOWN ALREADY

Female cynomolgus macaques, like women, show individual reproductive sensitivity to modest psychosocial and metabolic stress. During stress, resilient females ovulate through two menstrual cycles whereas stress-sensitive (SS) macaques immediately cease ovulation. On Day 5 of a non-stressed menstrual cycle, resilient macaques have less NE synthesizing enzyme [dopamine β-hydroxylase (DBH)], kisspeptin and GnRH innervation of the medial basal hypothalamus but more endogenous serotonin than SS macaques. Stress increased DBH/NE, kisspeptin and GnRH but did not alter serotonin.

STUDY DESIGN, SIZE, DURATION

In a longitudinal design, 27 adult (7-13 years) female cynomolgus macaques (Macaca fascicularis) with three different levels of sensitivity to stress were monitored with daily vaginal swabs and frequent serum progesterone (P) measurements. Three 90-day experimental periods called 'Cycle Sets' were monitored. A Cycle Set consisted of one ovulatory menstrual cycle without stress, and two cycles, or 60 days, with modest stress. Each Cycle Set was followed by a rest period. During a Cycle Set, individuals were either untreated (placebo) or administered escitalopram (CIT) or REB. Ultimately, half of each sensitivity group was euthanized during stress with CIT or REB treatment and the hypothalamus was obtained. Neurobiological endpoints were compared between CIT and REB treatment groups in stress resilient and SS monkeys.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The monkeys were housed at the University of Pittsburgh primate facility for the duration of the experiments. Upon euthanasia, their brains and serum samples were shipped to the Oregon National Primate Research Center. The hypothalamus was examined with immunohistochemistry for the expression of DBH (a marker for NE axons), kisspeptin and GnRH. P was measured in the serum samples by radioimmunoassay.

MAIN RESULTS AND THE ROLE OF CHANCE

Daily administration of REB restored ovulation in 9 of 10 SS animals during stress. Of note, REB significantly increased P secretion during stress in the most sensitive group (P = 0.032), which indicates ovulation. CIT lacked efficacy. REB significantly reduced DBH/NE, kisspeptin and GnRH axon density in the hypothalamus relative to CIT treatment (P = 0.003. 0.018 and 0.0001, respectively) on Day 5 of the menstrual cycle in resilient and sensitive groups.

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

The US FDA has not approved REB for human use, although it is used in Europe for the treatment of depression/anxiety as EdronaxTR. Whether REB could be useful for the treatment of FHA in women has not been determined.

WIDER IMPLICATIONS FOR THE FINDINGS

The use of an NRI to treat FHA is a novel approach and the potential reinstatement of ovulation could be straightforward compared to current treatment protocols. The underlying neurobiology provides a compelling case for treating the origin of the pathology, i.e. elevated NE, rather than circumventing the hypothalamus altogether with gonadotropins, which have associated risks such as hyperstimulation syndrome or multiple births.

STUDY FUNDING/COMPETING INTEREST(S)

Portions of this study were supported by NIH grant HD062864 to C.L.B., NIH grant HD62618 to J.L.C. and C.L.B. and 1P51 OD011092 for the operation of the Oregon National Primate Research Center. There were no competing interests.

Free Testosterone and Prolactin Levels and Sperm Morphology and Function Among Male Patients With Tramadol Abuse: A Case-Control Study

BACKGROUND/PURPOSE

Tramadol abuse has become a crisis in Egypt and many other Middle Eastern countries. Tramadol abuse is associated with sexual dysfunction and male infertility, according to recent animal and human studies. The objective of this study was to compare tramadol abuse patients and healthy controls regarding free testosterone and prolactin levels and semen analysis.

METHODS

Sixty patients with opiate use disorders attributed to tramadol (OUD-T) based on Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) diagnostic criteria and 30 healthy controls were included in the study. Sociodemographic and clinical data and urine, blood, and semen samples were collected from patients and controls for assessment.

RESULTS

Compared with controls, OUD-T patients had higher prolactin and lower free testosterone levels. Patients with OUD-T were more likely to have lower sperm count and higher abnormal motility and forms of sperms compared with controls.

CONCLUSIONS

Patients with OUD-T were found to be more likely to have lower free testosterone levels and lower sperm counts and vitality, and higher prolactin levels and sperm abnormal forms compared with controls.

The impact of emotional health on assisted reproductive technology outcomes: a systematic review and meta-analysis

This systematic review and meta-analysis has addressed ongoing controversy surrounding the association between pre-treatment anxiety, stress and depression and assisted reproductive technology (ART) outcomes. Medline, Embase and PsycINFO were searched up to November 2019. The eligibility criterion was observational studies reporting the association between pre-treatment anxiety, stress or depression and ART outcomes in men, women or couples undergoing ART. The association between pre-treatment anxiety, stress and depression and ART outcomes were extracted, and meta-analyses carried out if ≥3 studies assessed the same outcome over the same number of cycles and reported results homogeneously. The review reports a potential association between decreased sperm motility and increased male state anxiety, but no significant association between women's pre-treatment emotional health and ART outcomes in terms of live birth, clinical pregnancy, chemical pregnancy, oocyte retrieval, embryos transferred or fertilization. Meta-analyses showed no significant standardized mean difference (SMD) for anxiety/stress and clinical or chemical pregnancy, or depression and clinical or chemical pregnancy.

Urinary selective serotonin reuptake inhibitors across critical windows of pregnancy establishment: a prospective cohort study of fecundability and pregnancy loss

OBJECTIVE

To prospectively investigate the association of selective serotonin reuptake inhibitor (SSRI) exposure through critical windows of pregnancy establishment with fecundability and pregnancy loss.

DESIGN

Prospective cohort study using longitudinal urine measurements of common SSRIs while women are actively trying to conceive.

SETTING

Four clinical sites.

PATIENT(S)

A total of 1,228 women without uncontrolled depression/anxiety, attempting natural conception while participating in a randomized trial of preconception-initiated low-dose aspirin.

INTERVENTIONS(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Urinary SSRIs (fluoxetine, sertraline, escitalopram/citalopram) were measured while trying to conceive and, for women who became pregnant, at weeks 0, 4, and 8 of pregnancy. Fecundability odds ratios and incidence of pregnancy loss and live birth were estimated.

RESULT(S)

A total of 172 women (14%) were exposed to SSRIs while trying to conceive. SSRI exposure was associated with 24% reduced fecundability, and accordingly, a nonsignificant 9% lower live birth incidence, with significantly lower live birth in fluoxetine-exposed women. SSRI exposure was not associated with subsequent pregnancy loss, whether exposure was before conception or at 0, 4, or 8 weeks of gestation, although estimates varied by specific SSRI drug.

CONCLUSION(S)

Women using SSRIs may have more difficulty becoming pregnant, and although SSRI exposure overall was not associated with pregnancy loss, fluoxetine deserves caution and future study.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00467363.

Kisspeptin and RF9 prevent paroxetine-induced changes in some parameters of seminal vesicle fluid in the male rats

The aim of the study was to examine possible impacts of paroxetine and agomelatine on the levels of some components that constitute the seminal vesicle fluid. As a second purpose, it was also aimed to examine how possible negative effects induced by paroxetine on seminal vesicle fluid components were affected by kisspeptin and RF9 (an RFamide-related peptide antagonist, RFRP). Forty-two male rats, aged 21 days, divided into six groups; control, sham, paroxetine, agomelatine, paroxetine + kisspeptin and paroxetine + RF9. Paroxetine (3.6 mg/kg) and agomelatine (10 mg/kg) were administrated by oral gavage. Kisspeptin (1 nmol) and RF9 (20 nmol) were administered intracerebroventricular (i.c.v). The experiments were ended on post-natal 120 days; fructose, vitamin E, sodium, potassium and magnesium levels were measured in seminal vesicle fluid. Fructose, vitamin E, magnesium and potassium levels were significantly decreased in seminal vesicle fluid from the rats treated with paroxetine but did not show significant differences following agomelatine administration. The co-administration of kisspeptin or RF9 with paroxetine prevented the paroxetine-induced negative effects on seminal vesicle fluid components. These results suggest that reduction in sperm fertilising ability caused by changes in seminal vesicle fluid can be seen in long-term antidepressant use. RF-9 and kisspeptin might have positive effects on long-term antidepressant use-induced infertility.

Effect of diazepam, sertraline and melatonin on the stress-induced reproductive disorders and intrauterine growth restriction in female rats

Objective: Psychological stress is an important factor triggering depression and anxiety. Infertility is known to cause stress; however, it is not clearly known whether stress causes infertility as well. In addition, there are different opinions accounting for the relation of stress-induced oxidative stress to infertility and intrauterine growth restriction. The aim of the study is to examine the effect of sertraline, diazepam and melatonin on the infertility, intrauterine growth restriction and oxidative stress that can be caused by forced immobilization stress management (FISM) in female rats.Materials and methods: Wistar rats were grouped as healthy rats (HG) applied distilled water, stress treated control group (SC), and 20 mg/kg sertraline + stress (SS), 2 mg/kg diazepam + stress (DS) and 10 mg/kg melatonin + stress (MS) treated rats. The medicines were administered orally once a day for 30 days. At the end of this period, oxidant/antioxidant parameters were measured through the blood samples collected from the tail veins of all rats. Then the rats were kept in a suitable environment for 2 months for breeding.Results: FISM caused oxidative stress in blood serum of animals, infertility and intrauterine growth restriction (decrease in birth weight of the baby). Best medicines to suppress FISM-related oxidative stress are melatonin > diazepam > sertraline respectively, while sertraline > diazepam > melatonin were most successful in terms of preventing infertility. The best medicines preventing the FISM-caused intrauterine growth restriction were found to be melatonin > diazepam > sertraline, respectively.Conclusion: FISM causes oxidative stress in animals. Oxidative stress is understood to affect the intrauterine growth negatively although it is not a major component in the pathogenesis of infertility. While melatonin is only effective in preventing the oxidative stress-related intrauterine growth restriction, antidepressants and anxiolytic treatment were found to be helpful in preventing both infertility and intrauterine growth restriction.

Analysis of Expression and Functional Activity of Aromatic L-Amino Acid Decarboxylase (DDC) and Serotonin Transporter (SERT) as Potential Sources of Serotonin in Mouse Ovary

The origin of serotonin in the ovary is the key question for understanding mechanisms of serotonergic regulation of reproductive function. We performed a study of the expression and functional activity of the serotonin transporter (SERT) and the enzyme for the synthesis of serotonin, aromatic l-amino acid decarboxylase (DDC) in mouse ovary. A pronounced peak of SERT mRNA expression occurs at the age of 14 days, but serotonin synthesis enzymes are expressed at the maximum level in the ovaries of newborn mice. SERT is detected immunohistochemically in all cellular compartments of the ovary with a maximum level of immunostaining in the oocytes of growing ovarian follicles. DDC immunolocalization, in contrast, is detected to a greater extent in primordial follicle oocytes, and decreases at the later stages of folliculogenesis. Serotonin synthesis in all cellular compartments occurs at very low levels, whereas specific serotonin uptake is clearly present, leading to a significant increase in serotonin content in the oocytes of growing primary and secondary follicles. These data indicate that the main mechanism of serotonin accumulation in mouse ovary is its uptake by the specific SERT membrane transporter, which is active in the oocytes of the growing ovarian follicles.